Chapter 1: Inpatient Internal Medicine


Love, Sanity, or Medical School

Chapter 1: Inpatient Internal Medicine

July 1st: Monday

1:00 pm: They just handed me a pager. Now what?

I’m sitting in a barren, windowless classroom tucked away on a top floor within The General Hospital, surrounded by a small group of newly minted third year medical students. It’s our very first day on the wards. We are waiting for the chief residents to collect us and distribute us to the various medicine teams.

“Welcome to third year!” a smiling Dean of Something Educational had boomed across the packed med school auditorium earlier this morning during orientation. I didn’t hear many remarks past those beginning words of her requisite welcome speech because I became distracted catching up with my friends. I returned last night from vacation with my long time boyfriend and have not yet seen anyone. Aside from all my friends looking expectantly at me to share news that I do not have to share, while not so subtly glancing at my left ring finger, it was wonderful to see everyone.

Immediately following the welcome lecture we were treated to a talk about not letting residents and attending physicians physically, emotionally, mentally, and/or sexually torture you. Apparently our med school has a poor track record when it comes to abuse of third years. Funny how they don’t highlight those stats in the admissions brochure. 

2:15 pm: Still waiting…

It’s very convenient that my blue iPad mini fits comfortably in the pocket of my short white laboratory coat. Using the app Notability, my goal is to record the entire year in real time as it unfolds around me. Medical student secretly turned gonzo journalist!

3:30 pm: Apparently the chiefs didn't know that we, every medical student in the entire College of Medicine, were starting today so we sat there until three pm. We tried calling them. We tried paging them. Nada. Finally, an attending physician randomly passing by came to our rescue and located the chiefs. They seemed pleasantly surprised to see us all patiently sitting there for hours.

FYI- All medical students and residents move up the medical totem pole by one rung on July 1st. Always. If you’re a patient, avoid teaching hospitals in July. We’re all new to our respective roles.

3:55 pm: I met my team (a fourth year medical student, an intern, and a senior resident) and then was dismissed. Everyone seemed welcoming.

July 2nd: Tuesday

7:01 am: I have no idea what I'm supposed to be doing.

8:15 am: My attending, the young Dr. Osler, immediately comes across as friendly and enthusiastic. We discussed my goals for the rotation. His focus is on improving my patient presentation skills and learning to come up with broad differentials for my patient’s problems. Sounds good. My goals are to not embarrass myself and to not cry if I get yelled at. My first impression is that he doesn’t seem like the type of attending who torments third years, though I guess I’ll find out soon enough.

I officially have my own patient! He is in the hospital for a ginormous (proper medical terminology right there) foot ulcer.  I would call him FU for foot ulcer, but let’s go with McLovin’ instead. 

Having my own patient pretty much means checking in with him each morning before the team arrives and catching up on any new labs or overnight developments in his care (aka pre-rounding). I’ll write notes on his progress each day while helping plan for his discharge. Waaaay better than being in the classroom. The crux of having a patient is rounding. Each medical student and resident takes turns presenting their patients to the rest of the team during rounds. We hop around the hospital, traveling room to room, until we have checked in on every patient on our list.  Rounds are nerve wracking because it is imperative to know every single detail about their labs and work up, and all of your decisions regarding their care are debated and nitpicked. If the attending finds your management of a patient to be unsatisfactory the consequences may range from an eye roll, to an audible sigh, to a verbal berating, to being locked in a dungeon without food or water until such a time where your attending believes you can once again be let loose on the wards.

12:59 pm: Every Tuesday afternoon all students on the internal medicine rotation have class together from one o’clock to five o’clock. In an effort to make these four hours of lecture more exciting the internal medicine people have coined these afternoons, “Super Tuesdays.” Sure. Whatever. There are a lot of stereotypes in medicine- internal medicine folks are known to be super nerdy. So far, so true. And unfortunately I can’t go home afterwards because I’m on call tonight. Being “on call” on the medicine service basically means an extra long day, so instead of leaving at five pm I’ll be here until about 10 pm.

July 3rd: Wednesday

8:43 am: People take bad news very differently. A patient on our service was told his fiancé gave him Hepatitis C and he nonchalantly commented, "oh well, I'm marrying her anyway so I guess that's that." When the fiancé found out that she may have contracted Hepatitis B from him in return, she was NOT happy. I thought she was going to punch him or break the engagement right then and there.

10:15 am: While on morning rounds we met a new patient named Mr. BH who was admitted by the overnight team. He is suffering and in excruciating pain from multiple medical problems and a broken hip. As the overnight intern started presenting Mr. BH to our team, Mr. BH began reaching out past the intern and signaling for me to come closer. I was at the end of the bed and Mr. BH persistently motioned for me to move nearer to him. The whole time he was moaning in agonizing pain and it was confusing because we couldn’t figure out what he wanted. When I finally got close enough he grabbed my hand and held it tightly. Turns out he needed some comfort and just wanted to hold my hand.  He gripped my hand tightly the entire time we were in his room. It was very sweet, and very sad.  Pulling my hand away so I could grab my stethoscope and do a physical exam felt a little heartless.

Happy Fourth of July: Thursday

8:20 pm: It's hard to watch people in pain. A professor taught us last year that patients should never be in pain, should never be short of breath, and should not die alone. This is a deceptively difficult task though. Give too many meds and they stop breathing, give too few and their pain is intolerable and they lie in bed moaning. My team is trying to balance controlling Mr. BH's pain without causing a deadly respiratory depression.

Noon: My day was brightened when I ran into my sigo Casey. We met nearly seven years ago on a random Tuesday at a dive bar in Chicago. It wasn’t exactly love at first sight but there was definitely some spark, some attraction, so we began dating. Dating casually grew into a relationship, falling in love, and moving in together.

1 pm: My team is constantly busy and I feel like I'm in the way or at least just not on their radar this afternoon. Patients are very sick and I don't know my role yet.

I’m keeping myself busy by reading and studying.

2pm: I tried to learn to draw blood but was told by the intern, "don't waste your time, you'll never do that, nurses will do that for you". Only thing is, I want to learn and I'm bored because I don't know what else I could be doing right now aside from studying.

July 5: Friday

3:32 pm: I updated McLovin’ and his family. I answered his questions and then discussed his progress and discharge plans. It feels better than simply being out of the classroom, it feels like I am finally learning to be a doctor. Wonderful!

10:18 pm: I finally managed to sneak in a dinner with Casey tonight. It’s been forever since we've seen each other, which is impressive considering we live together and work at the same hospital. As he is a general surgery resident, his schedule is even worse than mine. His muscular former-football-player frame is still tan from our recent trip to Central America. Even with the unseasonable amount of rain we still managed to get in some scuba diving and visit the breathtaking Tikal Mayan ruins. Most importantly, I was able to check another box off my bucket list: I swam with sharks! It was a phenomenal experience. My love of the ocean and my most recent bucket list is not relevant at the moment though; I need to get some sleep because I’m on call again tomorrow.

July 6: Saturday

11:00 am- 4.5 hours down, 10 hours to go. The problem with Saturday call is that you have to come in post-call on Sunday. This means that my first day off since starting third year will be next Saturday.

Turns out drawing blood is a clinical skill requirement for this rotation.

McLovin’ is doing well and is going home tonight so hopefully I'll get another patient, maybe even two. It's hard knowing that I am the weakest link and that I slow the team down but there's really nothing I can do other than keep learning and try to improve as quickly as possible. In these couple of days my presentation skills, with the help of my attending Dr. Osler, have improved a lot. However, I still suck at describing wounds using proper medical terminology.

Dr. Osler: “Silvia, how you would describe this man’s ulcer?”

Me: "Um..." And I’m thinking to myself, well it smells really foul and looks super gnarly, as if someone took an ice cream scoop and scooped out a portion of the man's heel leaving behind a bloody, smelly, pus-filled hole. Hmm, need to learn how to translate that into words a grown up doctor would utilize.

I was right about Dr. Osler though, he is not one to torture medical students. He gives detailed feedback and frequently checks in with me- and has not once threatened to throw me in the brig! So far, so good.

Noon: The family of Mr. BH, the one who held my hand, updated his advanced directives to solely comfort care. Everything will be done to manage his pain but nothing else- no other medical interventions, no CPR, no intubation, nothing. His family believes that his quality of life will never again be at a point that he will find acceptable or enjoyable. In order to effectively manage his pain we need to increase his meds. Any time we did that in the past few days he would go into respiratory depression and get drowsy and hard to awaken so we’d back off with the dosage. However, alleviating pain is the only goal now. We increased his pain meds once again… which means he'll likely go into respiratory depression again... which means he will die.

3:30 pm: I was assigned my second patient. She's in for an intentional drug overdose. I know very little about liver physiology but I'll be able to put my Master’s degree in psychology to use so she’ll be a good patient for me.

July 7: Sunday

8:58 am: Nope, no I take that back- she is no longer my patient. Turns out her psychoses and medical management are too far beyond my meager third year skills. It sucks to realize that my Master’s degree in psych is not useful at all; I had envisioned being successful with dual diagnosis patients but no, just like everything else, I have to learn from scratch. Instead, I now have a sweet young girl named Barbie with a nasty eye problem under my care. 

It's weird waiting for someone to die. A resident from another team was like, “so, has your guy Mr. BH died yet?" It wasn't asked in a disrespectful way either, merely run-of-the-mill resident lounge conversation.

For the first time, and this may not happen again for a while, the senior resident on my team conceded, "You were right about your patient." I asked if Barbie could have some Ativan for her anxiety.  He firmly replied no, that she doesn't need any because she is young and healthy and shouldn't be given benzos because they’re addictive and potential dangerous and blah blah blah. But then he went and saw her in person and decided yep, Barbie is indeed super anxious and would benefit from a little Ativan. A small victory for the med student!

Barbie has an eye infection and must have eye drops placed every 30 minutes for 48 hours. A nurse will go in her room and literally pry open her sleeping eyes every 30 minutes for two full days. Wow. The alternative is she risks vision loss from not treating her infection properly. Omg she is going to be a zombie from the lack of sleep!

Speaking of zombies, there is another patient on my team with a leg infection that reminds me of a zombie wound every time I see it. You know those zombies where it looks like strips of skin got peeled off and it’s all beefy red underneath? That is exactly what this woman’s leg looks like. Creepy.

July 8: Monday

11:48 am: Our board scores are released on Wednesday. If you fail the boards you are immediately pulled off rotations and are not allowed to continue with third year until you have a passing score. Yikes. While I don't think I failed I know I will be incredibly relieved to see a passing score... any passing score.

I picked up another patient today, a young woman named Ms. AI with a difficult to control autoimmune disease. I didn’t actually offer to pick her up- she was assigned to me. No one on the team wanted her because apparently she’s super bitchy and argumentative. Amazing how quickly patients develop reputations. Ms. AI is emaciated from a string of recent illnesses. My goals are to help her gain weight, get her strength back, and get her labs under control. I wonder if she could sense that I was distracted while I was talking to her. No offense to her but my brain is entirely consumed with thoughts of my board exams.

3:12 pm: I keep offering to my team to let me do things but they keep saying, “It’s ok, we’ve got this,” or, “thanks but no thanks.”

July 9: Tuesday

6:30 am: Uh oh. Apparently Ms. AI has been moved to Step Down, a more acute care wing of the hospital. That’s bad. She became unresponsive overnight and a rapid response (not quite a code blue like when your heart stops and you’re actively dying but still really bad and people are concerned that you might code) was called on her. Scary. She seemed fine when I left last night…

11 am: Surprisingly, Mr. BH is doing well. Sure, we amped up his pain meds and risked killing him (at his family’s request, of course) but he pulled through. He has even been moved to a bed on a less acute floor. I'm too new to know whether or not this is surprising. All I know is my team felt fairly certain that this guy was going to die a couple of nights ago.

11:55 am: Barbie’s eyes are doing well; it looks like she may be able to go home tomorrow. It’s too soon to know for certain but it doesn’t seem that there will be any residual visual deficits.

3:50 pm: Very interesting ‘Super Tuesday’ lecture today. Really- not sarcastic. Our discussion today is on death and dying. Upon walking into the classroom we were promptly asked, "How do you want to die?" We all responded with ideas such as: at home, without pain, quickly, surrounded by family. Then we discussed the brutality and futility of CPR and that only 6% of patients were living six months after coding and receiving CPR.  On TV, we were informed about 75% of people survive such ordeals. Yes, I am typing while sitting in lecture. Shh, don’t tell- it looks like I’m taking notes. Anyway, talk about false hope and unrealistic expectations! 

People with terminal diagnoses who have time to plan their deaths have a higher likelihood of dying at home and surrounded by family compared to sudden deaths. I wonder whether or not physicians also have a higher likelihood of dying at home because they know the poor outcomes that result from aggressive life prolonging treatment. Hand is going up…

My professor really liked the question and suggested that I do a research study on the topic. I nodded noncommitally. I do find it interesting, so maybe one day... like when I’m done with my book and my bucket list and my current painting and the ten other things I always have going on at once. First month of third year is not the time to start tacking additional tasks onto my to-do list.

July 10: Wednesday

I experienced my first two rapid responses today. When you’re the “on call” team you carry the code pager. When the shrill rapid beeping starts blaring, you immediately stop what you’re doing and race toward whichever room is listed. Both turned out to be nothing but it was thrilling to head toward an unknown emergency. When people see you running, with your white coat flapping behind you and your stethoscope bouncing on your neck, they jump out of the way, flattening their backs up against the wall to let you pass while craning their necks to see what medical crisis you’re off to fix. To clarify, neither time did my own pager go off- I just obediently followed behind my team when they started running. There is a fundamental difference between people who get excited when they hear a code pager and those who cringe. Apparently I fall in the camp of people who get super excited. The codes were great distractions from worrying about my board score and also to break up the monotony of rounding. Turns out that rounding lasts for hours and is pretty darn boring.

10:45 am: Passed my boards! Barely. While of course I wish I had scored higher, I can't help but be so, so, so relieved that it's over and I am moving on with my classmates. My amazing mentor, The Boss, firmly stated in her email to me earlier today, "Do not be worried. You will excel in the clinical environment." I trust her advice and input implicitly so I will not worry. We’ve previously agreed that my strength is working with people and has never been, nor likely ever will be, taking multiple-choice tests.

2:30 pm aka 1430: I removed an internal jugular (IJ) central line from a patient, marking the first time this rotation I have touched a patient other than during a physical exam on morning rounds. While the internal med folks are all really friendly (bordering on non-confrontational), I don't see myself being in a specialty with this few procedures. I like getting my hands dirty.

Ms. AI was moved out of step down back to the floor. Good.

Turns out many end-of-life studies have been done and a greater percentage of terminally ill physicians die at home with no aggressive interventions compared to the average layperson. I direct interested parties to the 2012 article, "How doctors choose to die", published in The Guardian by Dr. Ken Murray. Very interesting. I think I will fill out a living will someday soon.

My intern and senior resident both let me draw blood from them. Bloody good fun. We were doing this in the break room and received many odd looks from people passing by in the hallway.

En route to see a new patient my senior resident shares advice that was given to him upon receiving his own board score: “Do not let your score influence your level of confidence.” I really appreciate hearing that- thanks. It was like he could read my mind and knew I needed a boost.

A patient disappeared today. Kind of impressive considering he is paraplegic and has minimal upper body strength. The patient is well known for screaming, flailing his arms, and spitting at any staff member who enters his room. Interestingly, the patient also refuses to put on a hospital gown so he has been lying in his hospital bed covered in strategically placed washcloths. To sum up, not just a paraplegic but a naked paraplegic managed to escape off of the floor this morning. Strong work floor staff.

July 11: Thursday

10:11 am: I have so much to learn.

11:42 am: Ask patients what they understand about their medical conditions- most have never had anything explained to them.

4:05 pm: The naked paraplegic was found and returned safely to the floor. Apparently he wheeled himself to the hospital courtyard where he was eventually found and brought back up to the floor. I’m not entirely sure if the goal was leaving permanently or just temporarily so that he could have a cigarette.

I just realized I never described the patient on whom I removed the IJ central line. Through a series of unfortunate events they had both hands amputated and in their place they now have intricate hooks. The dexterity and speed with which the patient maneuvers their hooks is pretty incredible. You try tearing open a sugar packet, pouring out just half into your coffee, deftly using a stirrer, then picking up the cup and drinking without spilling! I don’t know if it’s inappropriate to be so impressed. Maybe that is the typical level of functioning for someone with those types of prosthetics?

July 12: Friday

11:43 am: Tried going on rounds today without a stethoscope. Such a rookie.

Mr. BH has been discharged. Alive. Not a celestial discharge. Still in pain, still with a broken hip, but alive nonetheless.

Did you know that under very specific circumstances a hospital can pay for a plane ticket to send a patient back to their native country? Turns out that is an option being thrown around for a nasty patient on the floor right now.

3:12 pm: Ms. AI started throwing up blood. She is in constant pain. I don't know how to help her.

July 13: Saturday

Fifteen days in- my first day off since starting third year.

July 14: Sunday

Back at work. On call again. The internal medicine residents always seem nervous and hesitant to do things. We talk and talk and talk about patients and when we're done talking, we call a consult or two and then talk some more. I know these patients are complicated but commit to a choice and do something! I'm guessing their hesitancy is compounded by the fact that it is July and they are all probably scared to do something that could kill someone. I guess that’s understandable.

It's hard to give patients awful news and then clearly see on their face that they are rethinking all the poor decisions they have made throughout their life that led them to this point in time. Giving bad news makes me rethink all the shady things I’ve done in my life and whether by luck or chance, have never had to deal with any negative consequences of my occasional recklessness.

4:30 pm: The intern is too trusting. A patient came in with an abscess on the dorsum (top) of her hand, which ostensibly developed after she fell off a bike one week ago. She has no other injuries- not a scratch on her. She swore up and down to the intern and myself that she does not do drugs. Upon leaving her room I commented to the intern that I thought she was probably lying about her drug use. Her injury looks suspiciously as if she was injecting heroin into her hand. He replied, “No, there is no reason not to trust her”. Sure. We’ll see about this one. The intern and I present the patient to our senior resident and our senior agrees with me that yes, she is probably an IV drug user. The intern sticks to his guns. Again, as no one else wants her, she has been assigned to me. Let’s call this new patient of mine Ms. BA for bike accident.

5:45 pm: Urine drug screen on Ms. BA came back positive for all sorts of good stuff including opioids, cocaine, and marijuana. And that’s not even the fancy drug screen that picks up on designer drugs. Called it. Another win for the medical student.

July 15: Monday

It's shocking how many people have nasty foot problems from diabetes. The prevalence of diabetes makes me concerned for my dad- the disease is nearly ubiquitous among overweight Americans. He is out of shape, a former smoker, and has already had one heart attack. He is the poster child for a future diabetic and I worry about him constantly.

I just found out Ms. AI is being presented at M&M today. Why?? M&M, or, Morbidity and Mortality, is a conference where a patient who had a complication or who died, ostensibly due to a preventable medical error, gets presented to all of the medicine teams.  The teams then pick apart the case. The goal is to identify the cause of the problem so that it won’t be repeated by anyone else. In theory it’s a non-accusatory forum to address life and death errors but I’ve heard it can get pretty heated. Not quite like the TV show coming out called Monday Mornings but something to that effect.

Noon: morbidity and mortality conference. Here we go.

12:55 pm: OMG sitting in M&M while your patient is being presented is the worst thing ever- and I'm not even responsible for making decisions regarding her care. (I mean, I like to think I am but really, the residents make all the decisions and I just write her progress notes). The room of docs was provided with a barebones overview of her case, missing many of the details regarding the complexity of her condition. Then they start condescendingly talking about how they would’ve handled her case differently and perfectly. I wanted to yell out, “no, you don't get it, she is crazy unstable!” But I sat there quietly and watched my team face the firing squad while I hid in a corner.

July 16: Tuesday

7:53 am: Feet smell powerfully bad. Especially right after morning coffee.

9:14 am: Ms. BA is still swearing up and down that she does not use drugs. We keep going along with her story about the bike. No one will confront her. I don't think she should get more narcotic pain meds because she is drug seeking. Her abscess isn’t even that big and it’s healing really well. Hopefully she doesn’t go home and inject more heroin into it.

2:20 pm: Super Tuesday lectures are made infinitely more bearable by the presence of my closest guy friend, Magnus. We share a dry sarcastic humor and hold similar views on many issues ranging from patient care to football to the importance of bacon. Magnus and I became close because he dated my bestie Piper all throughout first year. The three of us would sit next to each other everyday during lectures and hang out whenever not in class. Piper broke up with him right after first year ended and fortunately they never once tried to put me in the middle of any of their drama as they did not speak to each other for the entirety of second year. Piper and Magnus are still two of my closest friends; I just have to hang out with them individually now. They've had shared custody of my friendship since their separation.

July 17: Wednesday

This morning I walked into Ms. BA's room to find her watching TV. She looks at me and deadpan tells me that her hand is killing her and she is in 10/10 pain. Not to be insensitive but if you can calmly and clearly tell me about your pain while lounging in bed watching soaps then it's probably not 10/10. Actually, it’s definitely not 10/10. 10/10 is more like childbirth to an extra large baby without an epidural; or a having a bone literally sticking out of your body in some weird angle, or having your leg bitten off by a shark with dull teeth. Those are examples of 10/10 pain in my book. I'm sure it hurts but really, I think she's drug seeking again and I have no interest in giving her more meds.

Ms. BA is getting under my skin because lying is a pet peeve of mine. While growing up my parents told my sister Olivia and I that they would never lie to us because once you catch someone in a lie, their word can never be trusted again. To this day, I still trust my parents. My parents are awesome. Ms. BA sucks.

1:00 pm: We have a patient on our service with a three-week old wound in the back of his head. There had been stitches and staples put in initially; staples all down the middle with one stitch at the top and two stitches at the bottom.  His staples were removed a week ago but the stitches were forgotten about for reasons unknown. I offered to remove the stitches because they had been in too long (stitches on the head usually are in ten to a max of 14 days). My team agreed this was a good idea but my intern wanted me to consult the trauma surgery team first. No. Bad idea. Calling the trauma team for their permission to remove THREE stitches on a well-healed wound would result in me either getting laughed at or yelled at by the trauma team. So I replied no, I wouldn't call. The intern retorted, “yes, you have to”. The intern then left to go do something else. I normally do not defy my superiors but this is ridiculous. To appease my intern I called Sophia (my dear friend and fellow medical student) who is currently rotating with the trauma surgery team. That way I could aver that yes, technically I did call the trauma team. She didn't answer (because the trauma team is always busy, which is why I didn’t want to call in the first place) and then I went and removed the stitches anyway.

3:00 pm: My intern is not happy with me. Fortunately the senior resident jumped in and defended me by explaining, “no, no, no, we do not consult trauma surgery for little things like that.” Phew. Yet another example of internal medicine people being terrified to do anything without the explicit permission of as many people as possible. Or another example of July interns being terrified to kill someone. Either way. But really, if you have three three-week old stitches holding the back of your head together then you have way bigger problems in your life than a rogue med student.

July 18: Thursday

One of the patients got me sick. It hurts to swallow. My throat is on fire. My tonsils are disgustingly swollen. It feels like strep but it’s likely something viral floating around. Ugh.

Night team gave Ms. BA more narcotics. Will people please stop increasing the pain meds on my drug seeking patient?! The senior resident reluctantly admitted to me that is was him that increased her dose. He explained that it was to make the night nurses lives easier. Ok, I get that but isn’t there any other option?

I would like to have an honest conversation with Ms. BA before she leaves about her behavior. I want to tell her that she really needs to stop using needles, especially dirty ones, because she will get more abscesses. My team informed me that the nature of medicine is to treat and not bother addressing problems for which there can’t be follow-up. Ok but what I don't understand is this: I have the time, I have the training, and I'm still naively optimistic enough to think that I can make a difference in her life. What is the harm if I go over options for treatment programs? Either way she is going home today. This whole time she thinks she's pulled one over on us. She thinks she is so clever and has successfully tricked the medical team into believing that her abscess is from a bike accident. In addition to paralyzing hesitation to do things, there is also a large amount of confrontation avoidance among the internal medicine people. Very frustrating. I'm too action-oriented and straightforward for this specialty.

A couple of weeks prior to coming to The General my other patient, Ms. AI, had a nasty infection that almost killed her. She had to be intubated and in the Intensive Care Unit (ICU) for a couple of days. She has extreme anxiety and nightmares about that hospital visit and she is terrified about the prospect of going to sleep, decompensating, and waking up intubated again. Her solution to this is to not sleep. She looks painfully tired and is fighting falling asleep. Her previous hospital experiences have been pretty traumatic. Another horrific experience was during one of her pregnancies, which resulted in her requiring an emergent cesarean delivery. She shared with me about being whisked away into a bright room, being surrounding by people in yellow gowns and having a mask put over her face. When she awoke she learned her baby had not survived the delivery. Poor Ms. AI. I want to give her a hug. If you know her, you probably don’t want to give her a hug because she’s pretty bitchy with the rest of the staff. But she’s chill with me for reasons unknown.

July 19: Friday

About an hour ago I received a text from my intern to go check in with Ms. AI because she is in a lot of pain. My mission was to figure out what was wrong and comfort her but offer no pain medication. After about two minutes of chatting she told me that on top of everything else going on she is having really bad belly cramps and muscles aches from starting her period. She is also suffering from crazy anxiety and depression. I talked with her a bit and regretted that I had nothing to offer her. As I was leaving an idea popped in my head. I randomly asked her if she would like to speak with our chaplain about her anxiety and for some spiritual comfort. She loved the idea- success! Found a way to support her and no meds required. Take that, intern.

I am feeling more and more ill as the day goes on and my energy is gone. Just want to curl up in bed. How sick do I have to be before I can leave? We were jokingly (?) informed during orientation that we would have to require IV fluids and IV antibiotics in order to be considered sick enough to not be at work.

July 20: Saturday

I kind of have the urge to check Ms. AI’s medical records from my home to see how she’s doing but I am off for the weekend so I will resist. It’s only my second day off from work in 20 days and my first full weekend off since I started third year.

My head is achy, I barely have the energy to sit up, and my ever-running nose is red and irritated from constantly being rubbed by tissues. I am not moving off my couch today. I wish I felt better so that I can enjoy my days off. Casey is on call so I have the house to myself. I don't think we've spent any real quality time together in days. Or months. It’s getting hard to tell whether this can be blamed on our schedules or if something else is the cause…

July 21: Sunday

After sleeping most of the past 24 hours I feel infinitely better and ready to rejoin the land of the living.

It was so gorgeously bright out today that I decided I needed to spend the day outside. I was in luck. Once a month the LGBT group at my medical school hosts a potluck dinner and as a mostly straight ally I try to attend each month. The hosts for this month are Dr. Penfield (who I adore) and his partner. Upon arriving, Dr. Penfield took my best friend Jane and I upstairs to the balcony overlooking his pool and backyard. From this vantage point he pointed out each of the physicians and their specialty so we would know whom to best target for networking. After about 10 minutes of playing who’s-who, two more people entered the backyard. Our professor confided to us, “Oh, look, that’s the medicine attending Dr. Osler. He’s started coming out to family and friends last week, but he hasn’t come out at work yet. It’s been really difficult for him. This is his first time ever attending the potluck; I’ve assured him it’s a safe place where he can be comfortable and open.” Well, I guess there’s no safer place to run into your own med student than at an LGBT potluck/pool party? 

I’m fairly certain Dr. Osler almost ran from the pool deck upon making eye contact with me. We chatted briefly and then each went about our own business of drinking and relaxing.

July 22: Monday, on call

11:35 am: There was a mandatory CPR recertification class this AM resulting in me missing morning rounds again. It feels weird to be away from my patients three days in a row.

11:46: Ugh the chaplain never checked in with Ms. AI on Friday! So much for that idea. And, turns out Ms. AI had a fall and developed a new infection. Why is she getting worse and not better?

2:35 pm: Ms. BA has been discharged. I wonder how long before she returns with her arm infected and requiring amputation à la Requiem for a Dream.

July 23: Tuesday

6:50 am: We have a new attending as of today so farewell to Dr. Osler. He was easy going and laidback, making it very easy for me to transition to third year. I've heard rumors that our new attending is very particular in how she likes things done and can be a really stickler about pretty much everything.

9:26 am: Many patients are condescending when we talk to them. They and their families often query: Do you know what you’re doing? Why am I not better yet? How old are you? Are you sure about that? I checked Google and I think I have xyx... We’re doing the best we can and don’t worry; our attending keeps a close eye on us.

11:46 am: Ms. AI has diarrhea so prolific right now that she has taken to wearing diapers. She tearfully admitted to me how embarrassing this whole situation is for her. We’re not that far apart in age. I really, truly can't imagine being in her position; it must be so, so terrible.

3:12 pm: My personal life is falling apart. Can I keep ignoring that right now?

July 24: Wednesday

11:49 am: We have a patient in his 90s who is likely not making it out of The General alive. His name is 95. His daughter, who is my parent’s age, made this realization while we were rounding yesterday. She broke down crying... Not just crying, but really sobbing. We were watching the moment where she came to understand that her father is not only mortal but is dying. My team left me with her during rounds to comfort her and I am so glad they did. I let her cry it out for a bit, then encouraged her to talk about 95 and her family. After awhile we discussed coping, strength, and surviving events we believe are insurmountable. After spending so many hours of so many days wishing I could be of service to my patients and my team this felt wonderful. This will certainly be a most memorable patient encounter.

On another note, 95 is one of the healthiest patients on our service- no diabetes, no cardiovascular disease, and he’s not obese. The senior resident informed me that if someone makes it to their nineties it’s because their life leading up until that point was likely very healthy. Evidently his health status is not surprising to anyone else on the team.

1:15 pm: My intern is off today, my senior is at clinic, and my attending is not here. I'm going to be a bad/ lazy med student and go home. I really need to go food shopping and take a shower. It’s been awhile.

July 25: Thursday

6:52 am: As I was pre-rounding today, Ms. AI told me to not to be so nervous when presenting in front of the new attending. I was touched to realize that this patient, someone so sick and brittle, had noticed how my bedside presentations changed with the new attending. And she is absolutely right on the money. This new attending definitely makes me jittery. I just wish my team could do more for Ms. AI. She appears to be fading before my eyes, every day more pallid and frail than the day before.

11:52 am: My team went into 95's room during rounds. While discussing the plan for 95, his daughter walked into the room. When she saw me she walked right over and gave me a big hug, then looked me in the eye, thanked me, and told me she'd never forget me. Great way to start the day! It would have been just as wonderful if my team wasn't present to witness her gratitude but having the team there was nice too.

7:35 pm: As part of my end-of-rotation evaluation I was observed while taking a patient history and doing a full physical exam. In general the feedback was positive. My attending highlighted that I am skilled at quickly developing excellent rapport with my patients. It's nice to feel that I'm good at something since most of the time I am fairly lost. Patients do not act the way we were taught they wound in the textbooks. During the physical exam she taught me how to properly palpate a spleen. From now on I won't have to awkwardly pretend as if I know what I'm doing during that part of an abdominal exam.

There's a NY Times article about patients developing PTSD after ICU stays. Patients at higher risk tend to be young females. I wonder if PTSD is plaguing Ms. AI during her hospital stay.

8: 36 pm: I am actively ignoring the fact that Casey told me on Monday night that he doesn't know if he ever sees us getting married.

July 26: Friday

11:30 am: 95 is a trooper. He’s doing great and will be going home tomorrow. Yet another patient this rotation that my team had written off for dead but will be going home very much alive.

2:15 pm: I had a final feedback session with my senior resident today. He said he was happy with me and went on to explain, “I don't want to use the word aggressive... No, your assertiveness in offering to do and watch procedures was great.” I told him I tried to keep an open mind during the rotation but we agreed that internal medicine probably isn't for me. Like in any way. At all. Ever.

I’m happy it's my last night of call with inpatient internal medicine and tomorrow is my last day at the hospital.  The next four weeks will be outpatient internal medicine. 

Since tomorrow is my last day I really need to go say goodbye to Ms. AI.

3:35 pm: Timing. Not a minute after typing the previous sentence the code pagers went off... I took off running and was halfway down the hallway to the patient’s room before it clicked that I was heading towards Ms. AI room. She went unresponsive so a code was called. Then she started posturing, with her arms and legs extended stiffly at her side. The MD at her side pinched her hips too hard to see if she was responsive. She wasn’t. I wanted to yell at him to stop. I stood frozen near the doorway of her room and watched her get intubated while the residents discussed whether or not she may have developed a bleed in her head. The scene played out exactly the way she described to me that she was afraid it would happen. Masked, yellow-gowned docs swarming around her bed and shoving a tube down her throat. She was sent for an emergent head CT so I went with her, and then I followed her to her new room in the ICU. I sat with her awhile, unable to imagine how I would feel if one of my nightmares came true. One of the attending docs stopped and asked me if I was ok. I’m usually good at hiding my emotions but this was too much to witness. She can’t die. She can’t. Of all the patients… not her. Please not her.

5:45 pm: Time does not stop and our team is busy. There is a new patient for me… and I almost just vomited in his room because of the smell emanating from him.

6:50 pm: Lots of new patients are rolling in- two that are psychotic. Psychotic patients are very entertaining to me at baseline and today they are also distracting me from thinking about Ms. AI. One new patient kept yelling at me and calling me Bessy. The other one is very paranoid and believes she is part of an FBI conspiracy and film project. She seemed relieved (though I think slightly disappointed) when I firmly told her that no, we are not making a movie about her.

July 27: Saturday

6:45 am: Today is my last day on inpatient medicine.  I would've said goodbye to Ms. AI but she is still intubated in the ICU. I will however go and say goodbye to 95 and his wonderful family once we’re done with rounds.

1:30 pm: Wow, what a great note to end on. I spent nearly 40 minutes sitting with 95 and his wife of forever.  They have many children and even more grandchildren and great grandchildren. 95’s wife revealed to me in a conspiratorial tone, “Every time he thought I wasn’t busy enough he got me pregnant again.” My favorite exchange went something like this:

Wife: “I couldn’t have found a better man, I am so blessed.”

95: “You could’ve found a richer man.”

Wife: “I guess so…”

95: “Eh, but he probably wouldn’t have you let you spend all his money the way I let you spend all of mine!”

And then two of them busted out laughing. 95’s wife then asked me if I had a boyfriend. When I replied, “yes” she told me that he better be treating me right.  She then added that he must be worried all the time about other doctors hitting on me. I’m not so sure about that, but I just nodded and smiled and left it at that. There were lots of hugs and well wishing when I left the room. I am in awe of their relationship. You could see the love between them, emanating from them. My grandparents, my mom’s parents, were like that. Hugging and kissing and holding hands up until the day my poppa died. My relationship with Casey isn’t like that; it hasn’t been like that in a long time. Maybe in the past, but not recently. I’m dreading going home today and discussing the state of our relationship but I can’t put it off any longer.

Before I leave the hospital and officially finish inpatient medicine I go turn in my pager that never went off.

End of Chapter 1